This is a blog by a former CEO of a large Boston hospital to share thoughts about hospitals, medicine, and health care issues.

Sunday, April 08, 2012

Check yes or no, not both!

I am giving a keynote presentation about reducing medical errors at the annual Health Care Quality Summit of the Saskatchewan Health Quality Council in a couple of weeks and was asked to fill out the usual forms beforehand. In so doing, I inadvertently demonstrated one of the dangers of checklists. As a nurse colleague once said to me, if you create a checklist, people will check it.

Indeed, in the wrong side surgery I have discussed from time to time, the circulating nurse actually checked the portion of the patient record indicating that a pre-surgical time-out had taken place, even though it had not. Why did she do that? Well, she had left the OR briefly, and when she came back the procedure had started. Therefore, she assumed that the time-out had taken place and checked off the box in the patient record to document the "fact." (The new protocol makes that not possible: The nurse has to witness the time-out.)

In short, unless there is a thoughtful work process underlying a checklist, it can still permit failure.

In my case, no harm was done. My host gently wrote:

I was just reviewing the contract that you signed and noticed you
checked both boxes (as included in the image below). Could you clarify
which one you are consenting to? Can we video record you to make parts
of your presentation available online? You are keeping us on our toes!

Also, the very act of having to check a box can change our 'decision'. Dan Ariely has pointed out that the discrepancy between high and low organ donor rate countries hinges on whether they have an opt-in or opt-out system. In either case, individuals check a box on a form, but faced with a weighty choice most frequently default to inaction, leaving the box blank. That's good for donor recipients in opt-out countries!

Nice example. It does illustrate the need for clearer checklist design. The options provided in the image seem to me to be far too wordy. What if they had written out the main query, then asked you to simply check off yes or no? It would likely reduce a great deal of the rework of having to check with people who absentmindedly check both boxes.